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PubMed1995

Understanding the essentials of economic evaluation.

Economic evaluation (EE) answers the following simple question: "From which course of action do we get the most value for our money?" We ask this question because resources are always limited, i.e., we never have enough money to do all the things we would like to do. Three types of economic evaluations are used: cost-effectiveness analysis, cost-utility analysis, and cost-benefit analysis. Although all involve a monetary and outcome comparison of two or more courses of action, the methodologies and outcomes of each type vary, making each one particularly suited for specific and different indications. Although the performance of an EE may be complex, its concept is intuitively simple. Understanding the basic elements of economic analysis is more and more important to all health-care providers because health-care policy makers at all levels are increasingly using EE for allocating resources.

Acquired Immunodeficiency Syndrome↗
PubMed1998

A pharmacoeconomic model to aid in the allocation of ambulatory clinical pharmacy services.

Drugs of choice in secondary prevention strategies reduce complication rates of certain diseases. Unfortunately, these strongly indicated drugs remain underused. A model was developed to predict the cost-effectiveness of clinical pharmacy services assumed to improve use of drugs of choice to unity in hypothetical cohorts of three diseases that commonly accompany hypertension and in which clear drugs of choice exist. Use of angiotensin-converting enzyme (ACE) inhibitors in patients with diabetes who have proteinuria, use of beta blockers after myocardial infarction, and use of ACE inhibitors in patients with asymptomatic left ventricular dysfunction were analyzed. Clinical pharmacy services could be cost-saving in all three diseases in this model if use of the drug of choice in standard practice did not exceed 0.899 in patients with diabetes who have proteinuria, 0.512 in patients after infarct, and 0.804 in patients with asymptomatic left ventricular dysfunction. This model may help decision makers by accessing local patient demographics and prescribing habits before any resource allocation.

Adrenergic beta-Antagonists↗
PubMedDate not supplied

Primary health care is viable.

'Selective primary health care' and other recent vertical health strategies have been justified on the grounds that the broad primary health care (PHC) approach cannot be afforded by developing countries in the present constrained economic circumstances. This judgement is too sweeping. A simulated case example is presented, starting with baseline health expenditure data that are representative of the situation in many developing countries. It is assumed that real economic growth occurs and that government funding of health care is allowed to grow in parallel. Two annual growth rates are considered: 2 and 5 per cent. Two restrictive conditions are applied: none of the main health services is subjected to absolute cuts; and, additional funds from existing or new sources of finance are not considered. It is shown that, even with slow growth rates, substantial increases in the funding of priority (rural and PHC) services can be achieved if the growth in expenditures of lower-priority services is curtailed. Also, savings from improved health service efficiency can be channelled to priority services. The message is that the PHC approach is viable even with slow economic growth. What is required is the technical capacity to identify and plan resource flows in the health sector, and the political will to effect resource allocations according to PHC priorities. A strategic policy like PHC should not be 'adjusted' out of effective existence because of reversible economic problems. Rather, actions should be taken to reverse the adverse economic environment. International health-related agencies should continue to support countries to develop national health systems based on PHC, and should campaign for reforms in the world economy to create at least the minimum economic conditions necessary for PHC implementation.

Data Collection↗
PubMed2004

Effects of body size and temperature on population growth.

For at least 200 years, since the time of Malthus, population growth has been recognized as providing a critical link between the performance of individual organisms and the ecology and evolution of species. We present a theory that shows how the intrinsic rate of exponential population growth, rmax, and the carrying capacity, K, depend on individual metabolic rate and resource supply rate. To do this, we construct equations for the metabolic rates of entire populations by summing over individuals, and then we combine these population-level equations with Malthusian growth. Thus, the theory makes explicit the relationship between rates of resource supply in the environment and rates of production of new biomass and individuals. These individual-level and population-level processes are inextricably linked because metabolism sets both the demand for environmental resources and the resource allocation to survival, growth, and reproduction. We use the theory to make explicit how and why rmax exhibits its characteristic dependence on body size and temperature. Data for aerobic eukaryotes, including algae, protists, insects, zooplankton, fishes, and mammals, support these predicted scalings for rmax. The metabolic flux of energy and materials also dictates that the carrying capacity or equilibrium density of populations should decrease with increasing body size and increasing temperature. Finally, we argue that body mass and body temperature, through their effects on metabolic rate, can explain most of the variation in fecundity and mortality rates. Data for marine fishes in the field support these predictions for instantaneous rates of mortality. This theory links the rates of metabolism and resource use of individuals to life-history attributes and population dynamics for a broad assortment of organisms, from unicellular organisms to mammals.

Animals↗
PubMed1987

Hospital and community health service costs: England and Scotland compared.

In publications which have compared the health expenditure in the component parts of the United Kingdom by applying the Resource Allocation Working Party (RAWP) formula to the health budget of England, Scotland, Wales, and Northern Ireland it has been previously concluded that Scotland's hospital and community health services expenditure is more than 19% above what would be a fair distribution. It has also been implied that Scotland's allocation should be cut substantially to improve services in England. On the assumption that the purpose of examining the distribution of the health and community health service budget is to ensure "equal opportunity of access to health care for people at equal risk" it is concluded that simple RAWPing of the United Kingdom budget is flawed and a conclusion based on this is therefore untenable.

Community Health Services↗
PubMed1986

Strategies for equity in health: report from Sweden.

In recent years the Swedish debate on health policy has been focusing on resource allocation between primary care versus secondary care, private care versus public care, and prevention versus care. The National Commission on the "Swedish Health Services in the 1990s" brought attention to the prevailing inequalities in health. The Health Policy Bill of 1985 defines the reduction of inequalities in health as a major target of national health policy. The health policy measures discussed are mainly outside the health care sector.

Adolescent↗
PubMed1995

Age changes in the distribution of visual attention.

Two experiments examined adult age differences in the controlled allocation of visual selective attention. Both experiments were identical with the exception of the stimulus display where targets and distractors were linearly increased with eccentricity in Experiment 2. A spatial cuing task was used with four cue-target presentation intervals (SOAs) of 250, 500, 1000, and 2000 msec (Experiment 1) and 250, 500, 750, and 1000 msec (Experiment 2). Results were fit to three quantitative models based on attentional distribution metaphors (spotlight, zoom lens, and ring) in order to determine the best fitting model of attentional distribution. Data from Experiment 1 indicated that older subjects distributed attention in a qualitatively different manner than younger subjects and suggested a different time course of processing. When stimuli visibility was controlled a single flexible resource allocation (ring) model of attention could account for the results of both age groups at all SOAs. Results further suggested that older adults employ compensatory strategies to offset visual processing difficulties.

Adult↗
PubMed1993

Trends in program project grant funding at the National Cancer Institute.

In summary, analysis of the P01 program indicates that differences exist in scores and funding requirements between purely basic and translational P01s; P01 funding has been stable and the P01 policies consistent; growth in average costs for P01s has lagged compared to R01s; P01 grantees have a higher success rate than R01 grantees; priority score compression reduces the P01 payline without reducing the number of grants funded; exception funding in P01s expands the number of grants awarded and helps to meet the scientific program needs of the NCI; almost all R01 and P01 applications in the first quartile are funded; comparably ranked R01s and P01s are funded at equivalent percentages of recommended funding levels; the percentage of approved funds awarded declines as scores for R01s and P01s become less favorable. Because the resources available are finite, the NCI carefully considers the competing demands for RPG funds. On balance, however, the P01 program is still in good health. In combination with the other methods we use to make RPG awards, the P01 program is a vital component of our research grant program. Faced with budget realities, however, some difficult decisions have to be made. The NCI is open to suggestions on how to distribute research funds to best promote cancer research throughout the country. The NCI is particularly interested in hearing researchers' perceptions of problems so that, whenever it is appropriate, we can modify our course. There are important questions to consider for the future. Should there be greater or lesser use of RFAs in allocating resources for P01 grants? What algorithm optimally distributes resources among R01s, P01s, and other funding instruments in the RPGs? Should exceptions be used more or less heavily in the P01 funding process? Should other grant programs outside the RPG budget, such as the P50 SPORE program, be used to relieve pressures on the P01 budget? Should the number of projects within P01s be limited? How can peer review groups be given opportunities to provide priority scores that better reflect distinguishable differences in highly meritorious P01s? Should P01 scores be normalized? How could the R01 percentile concept be applied to P01s? How can the results from standing study sections be synchronized with results from ad hoc review groups? What changes in peer review procedures would promote equitable score distributions and budget recommendations across years? How can the NCI provide stability for established P01s without impinging on the ability of new P01s to enter the system?(ABSTRACT TRUNCATED AT 400 WORDS)

Financing, Government↗
PubMedDate not supplied

Home care of the frail elderly in the United Kingdom: matching resources to needs.

The paper reports the essential features and evaluation of a scheme to improve the effectiveness of home care for the frail elderly. Decisions about resource allocation were devolved to front line social work staff giving them greater autonomy within clear expenditure parameters. More imaginative responses were noted in the management of a number of difficult problems and the results of the evaluation were generally positive. It appeared that the scheme was most cost-effective for the extremely mentally and physically frail living with others and also for the less frail, socially isolated, depressed elderly person.

Aged↗
PubMed2002

Impact of a dedicated syncope and falls facility for older adults on emergency beds.

BACKGROUND: syncope and falls are common symptoms in older adults. Dedicated facilities for these symptoms are emerging in the UK. To date, justification for resource allocation for these day case facilities is lacking. A dedicated syncope and falls day case facility for older adults was set up in Newcastle in 1991 (at the Royal Victoria Infirmary). The facility provided rapid access for assessment of appropriate patients from the community, the accident and emergency department, or emergency admissions. Activity and performance in 1999 were compared with peer inner-city teaching hospitals and with previous performance in 1990 at the Royal Victoria Infirmary to determine whether the facility had influenced emergency activity. OBJECTIVE: to describe the impact of the facility on emergency bed activity and performance for the diagnostic categories of syncope, falls, collapses, gait abnormalities and dizziness. DESIGN: descriptive study. SETTING: syncope and falls day case facility. METHODS: performance and activity for Healthcare Resource Groups and ICD codes relevant to falls and syncope were compared for adults over 65 years attending the Royal Victoria Infirmary and thirteen peer hospitals. Activity and performance before the facility was set up (1990) at the Royal Victoria Infirmary were also compared with 1999 data. RESULTS: syncope and collapse is the 6th commonest reason for acute hospital attendance of over 65-year olds in the UK. In 1999, the Royal Victoria Infirmary was at variance by-6616 bed days compared with other the other Trusts for these diagnoses. This equates to 18 beds occupied in that year. The degree of emergency activity for the relevant diagnoses (Healthcare Resource Groups data) was much less than at peer trusts-35% versus 97%. The average length of stay for admitted patients was also shorter for Royal Victoria Infirmary than peers-2.4 versus 8.6 days. Acute length of stay at the Royal Victoria Infirmary was reduced from 10.9 days in 1990 to 2.7 days in 1999 (ICD 10 data). In 1991 all activity was emergency. CONCLUSION: the striking variance in bed days in 1999 is due to lower emergency activity and shorter length of stay at the Royal Victoria Infirmary. This is attributed to the dedicated rapid access day-case facility. This has relevant resource implications for planning of future facilities and implementation of National Service Framework standards for falls and intermediate care.

Accidental Falls↗
PubMed1999

Attentional resources in major depression.

Depression appears to interfere more with effortful processes than with automatic processes. This study aimed to examine attentional resources allocation by means of RT on effortful detection tasks. Ten depressed inpatients during illness and at recovery and ten healthy control subjects were given simple and choice reaction time tasks. Two types of effort demanding conditions were assessed (1) the combination of two concurrent tasks and (2) tasks involving decision making. Depressed patients improved from single to dual tasks whereas recovered and control worsened. Depressed patients showed a significant time and accuracy impairment when decision processes were involved. The decision making impairment co-occurred with a deficit in the orientation of the attention. The decline with decision making was not worsened when the choice task combined with a concurrent task and was reversible with recovery. This pattern of results exhibits differential sensitivity between two effortful tasks. Depressives may be able to mobilize resources to complete effortful tasks as far as decision processing is not required.

Adult↗
PubMed2003

[Waiting list situation at a regional hospital].

BACKGROUND: In Norway, waiting lists generated by the national VENTSYS system are used for hospital management and resource allocation. MATERIALS AND METHODS: Data were obtained from monthly reports from VENTSYS and the hospital's annual reports. General development in waiting parameters was analysed for the period 1997-2002. The number of patients waiting in January 2002 was compared to the total number of treated patients in 2001 (capacity). RESULTS: Waiting list numbers were stable. The number of patients on the lists corresponded to only 8% of patients treated. There was no correlation between capacity and number of patients on waiting lists for more than twelve months, or between capacity and average length of time on a list. Only a few departments had waiting lists corresponding to more than a few months' throughput. INTERPRETATION: Long waiting lists and waiting time are better explained by poor patient logistics and booking systems than by lack of resources.

Hospitals, District↗
PubMed2000

Disease management. A global cost-containing initiative?

Disease management has been marketed by healthcare industry providers as a way of improving resource allocation in healthcare and containing costs. However, to achieve improved efficiency in healthcare requires the guidelines and protocols in the disease management process to be based on sound evidence of effectiveness and cost effectiveness. This has not always been the case. The approach itself has an inadequate evidence base in terms of randomised controlled trials, other rigorous methods of evaluation and the results of economic evaluation. Disease management can be viewed as an attempt by pharmaceutical companies to undertake forward vertical integration into other parts of the healthcare process. This could reduce uncertainty for purchasers and reduce transaction costs, thereby potentially facilitating both healthcare expenditure control and efficiency. However, such cost savings may be outweighed by a concentration of power in disease management (pharmaceutical) companies, and the exploitation of such power to inflate expenditure and misallocate resources. Disease management must be appraised with care.

Cost Control↗
PubMed1980

Use of nondifferentiable optimization in a health care problem.

Those who study health care systems (HSC) seek to model the features of health care systems of societies that are common to different countries, so as to assist those who plan health services. The mathematicians interested in nondifferentiable optimization (NDO) seek to extend the classical optimization techniques to functions that have "non-smooth" regions where no unique gradient can be defined. This article reports how a health resource allocation model was solved by minimizing a function with points of nondifferentiability. It describes how an example of the model arose in the joint strategic planning of health and personal social services in a county in England with a population of about one million. It also formulates the model as a problem of NDO. Ways to obtain numerical solutions are reviewed, and the solution of the example by NDO is compared to another method based on linear approximation.

Aged↗
PubMed1999

More severe mental illness is more concentrated in deprived areas.

BACKGROUND: The greater frequency of mental illness in deprived and inner-city populations is well recognised; allocation of funds in the UK health service makes some allowance for this. However, it is not clear whether the differences are similar for all levels of mental health care need. AIMS: To study the range in prevalence of mental health problems and care at primary care, general secondary care and forensic care levels. METHOD: We used mainly descriptive statistics to study evidence available from existing sources--some based on indicators of likely need, some on observed prevalence of treatment. RESULTS: Among English health authority areas, the most morbid have about twice the prevalence of primary care level mental illness of the least morbid. For secondary care the ratio is between 2.5 and 4 to 1, while for services for mentally disordered offenders it is in excess of 20:1. CONCLUSIONS: Where needs indices are used for resource allocation, responsible authorities should ensure that they produce ranges reflecting the full compass of services funded. For forensic services the range of morbidity levels may be so great that funding needs to rest at a larger population level than that of health authorities.

England↗
PubMed2006

Variation in defence strategies in two species of the genus Beilschmiedia under differing soil nutrient and rainfall conditions.

The relationships between various leaf functional traits that are important in plant growth (e.g., specific leaf area) have been investigated in recent studies; however, research in this context on plants that are highly protected by chemical defences, particularly resource-demanding nitrogen-based defence, is lacking. We collected leaves from cyanogenic (N-defended) Beilschmiedia collina B. Hyland and acyanogenic (C-defended) Beilschmiedia tooram (F. M. Bailey) B. Hyland at high- and low-soil nutrient sites in two consecutive years that varied significantly in rainfall. We then measured the relationships between chemical defence and morphological and functional leaf traits under the different environmental conditions. We found that the two species differed significantly in their resource allocation to defence as well as leaf morphology and function. The N defended species had a higher leaf nitrogen concentration, whereas the C-defended species had higher amounts of C-based chemical defences (i.e., total phenolics and condensed tannins). The C-defended species also tended to have higher force to fracture and increased leaf toughness. In B. collina, cyanogenic glycoside concentration was higher with higher rainfall, but not with higher soil nutrients. Total phenolic concentration was higher at the high soil nutrient site in B. tooram, but lower in B. collina; however, with higher rainfall an increase was found in B. tooram, while phenolics decreased in B. collina. Condensed tannin concentration decreased in both species with rainfall and nutrient availability. We conclude that chemical defence is correlated with leaf functional traits and that variation in environmental resources affects this correlation.

Acclimatization↗
PubMed1996

Recommendations of the Panel on Cost-effectiveness in Health and Medicine.

OBJECTIVE: To develop consensus-based recommendations for the conduct of cost-effectiveness analysis (CEA). This article, the second in a 3-part series, describes the basis for recommendations constituting the reference case analysis, the set of practices developed to guide CEAs that inform societal resource allocation decisions, and the content of these recommendations. PARTICIPANTS: The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS). EVIDENCE: The panel reviewed the theoretical foundations of CEA, current practices, and alternative methods used in analyses. Recommendations were developed on the basis of theory where possible, but tempered by ethical and pragmatic considerations, as well as the needs of users. CONSENSUS PROCESS: The panel developed recommendations through 2 1/2 years of discussions. Comments on preliminary drafts prepared by panel working groups were solicited from federal government methodologists, health agency officials, and academic methodologists. CONCLUSIONS: The panel's methodological recommendations address (1) components belonging in the numerator and denominator of a cost-effectiveness (C/E) ratio; (2) measuring resource use in the numerator of a C/E ratio; (3) valuing health consequences in the denominator of a C/E ratio; (4) estimating effectiveness of interventions; (5) incorporating time preference and discounting; and (6) handling uncertainty. Recommendations are subject to the ¿rule of reason,¿ balancing the burden engendered by a practice with its importance to a study. If researchers follow a standard set of methods in CEA, the quality and comparability of studies, and their ultimate utility, can be much improved.

Cost-Benefit Analysis↗
PubMed2000

A cost-benefit analysis of mechanical ventilation. An examination of DRG 475.

OBJECTIVE: An economic evaluation of the resources used for mechanically ventilated patients using various measures for the benefits of extending life. METHODS: Regression analysis is applied to New York State discharge data for patients under DRG 475 during 1992-96 to predict age-specific survival rates and payments per life saved. Sensitivity analysis is used to compare benefits of extending life associated with different economic values of life with the payments per life saved at each age. RESULTS: Payments per life saved decreased over time, primarily due to reduced reimbursements. Payments exceeded the age-adjusted and the quality-of-life and age-adjusted benefits for all economic values of life at ages 90 and older. CONCLUSIONS: Since the benefits of extending life associated with DRG 475 exceed the payments per life saved at most ages, economic evaluations may be best applied with psychosocial evaluations to allocate resources more ethically.

Adult↗